19 Feb Evaluate the guidelines for the use of mood-stabilizing agents..pdf

Objective: Apply the guidelines for the use of mood-stabilizing agents with reference to classification, dose and administration, effects and side- effects, routine investigations in monitoring of patients.

1. Evaluate the guidelines
for the use of
mood-stabilizing agents.
Pharmacology 3
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2. Objectives
•2.1 Apply the guidelines for the use of mood-
stabilizing agents with reference to classification,
dose and administration, effects and side-
effects, routine investigations in monitoring of
patients.
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3. Mood-stabilizing agents
•Mood-stabilizing agents are medications primarily used to manage
mood disorders, particularly bipolar disorder.
•These drugs help stabilize mood swings and prevent episodes of
mania or depression.
•Bipolar disorder, formerly called manic depression, is a mental health
condition that causes extreme mood swings that include emotional highs
(mania or hypomania) and lows (depression). When you become depressed,
you may feel sad or hopeless and lose interest or pleasure in most activities.
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5. Indications
•One of the strongest indications for mood stabilizers is bipolar
disorder, a mood disorder comprised of two types.
•Bipolar I disorder is defined by at least one manic episode in a
lifetime, while bipolar II disorder is defined by at least one past or
present hypomanic episode with at least one past or present major
depressive episode.
•The manic and depressive characteristics of bipolar disorder require
particular mood stabilizers that can cater to the patient’s individual
needs.
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6. Indications
•Different agents belonging to the mood stabilizer class of medications
have strengths and weaknesses owing to their indications,
contraindications, and their protocol for follow-up.
•Clinicians are encouraged to choose a mood stabilizer keeping these
different factors in mind so that patient outcomes may improve by an
informed choice made in the pharmacological management of
patients with bipolar disorder.
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7. FDA-Approved Indications
•Lithium has approval as monotherapy or combination therapy for
acute manic episodes and as maintenance therapy in bipolar disorder.
•Divalproex is approved as monotherapy or combination therapy for
acute manic episodes and may be used for complex partial, simple,
and absence seizures and as migraine headache prophylaxis.
•Carbamazepine has approval for monotherapy and combination
therapy for acute manic and mixed episodes in bipolar disorder and
may additionally be a treatment for seizure disorders and trigeminal
neuralgia.
•Lamotrigine is approved for maintenance therapyin bipolar disorder
and also as an anti-seizure medication.
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8. Ahypomanicepisodeisadistinctperiodofabnormallyandpersistentlyelevated,expansive,or
irritablemoodandincreasedenergyoractivitythatlastsforatleastfourconsecutivedaysandis
clearlydifferentfromtheindividual'susualbehavior.HypomanicepisodesareakeyfeatureofbipolarII
disorderbut can also occur in other mood disorders.
•Elevated Mood: During a hypomanic episode, individuals may experience an unusually elevated or euphoric
mood. They may feel exceptionally happy, confident, or optimistic, often without a clear reason.
•Increased Energy and Activity: Hypomania is typically associated with a significant increase in energy levels
and goal-directed activity. Individuals may feel restless or constantly on the go, engaging in multiple activities
simultaneously.
•Decreased Need for Sleep: People experiencing a hypomanic episode may feel less need for sleep than
usual. They may report feeling rested after only a few hours of sleep or may experience insomnia.
•Racing Thoughts: Hypomania is often characterized by racing thoughts, rapid speech, and an accelerated
flow of ideas. Individuals may jump from topic to topic, have difficulty concentrating, and may be easily
distracted.
•Grandiosity: Some individuals may experience feelings of grandiosity or inflated self-esteem during a
hypomanic episode. They may have exaggerated beliefs about their abilities, talents, or importance.
•Increased Risk-Taking Behavior: Hypomania can lead to impulsivity and an increased willingness to take
risks. This may manifest as reckless driving, excessive spending, engaging in sexual activity, or making
impulsive decisions without considering potential consequences.
•Psychomotor Agitation: Individuals may exhibit psychomotor agitation, such as restlessness, pacing, or
fidgeting.
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9. Mechanism of Action
•Although there is still more to discover about the particulars of
lithium, valproicacid/divalproex, and carbamazepine, a suggested
common mechanism for their mood-stabilizing abilities is inhibition
of the inositol uptake process, resulting in inositol depletion.
•In this proposed mechanism, the myo-inositol monophosphate
transporter and its respective mRNA become downregulated by the
above-mentioned three major mood-stabilizing agents.
•The mechanisms of individual key mood-stabilizing agents are
discussed in further detail on the next slides
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10. •Carbamazepine:Carbamazepine follows suit with the other mood-
stabilizing agents mentioned, with an additional specific mechanism
of action identified wherein cAMP accumulation becomes inhibited,
resulting in the downregulation of the inositol transporter.
•Lamotrigine:Lamotrigine, like valproate, is an anticonvulsant. Its
mechanism of action involves reducing only the frequency (and not
amplitude) of excitatory postsynaptic currents in the CNS, causing a
decrease in glutamate release while causing a concomitant increase in
frequency and amplitude of inhibitory postsynaptic currents, which
enhances GABA release. Therefore, lamotrigine causes opposite
effects on glutamate and GABA transmission, downregulating
glutamate release and increasing GABA release.
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11. Administration
•Lithium is currently available for use in tablets, capsules, and solution
forms.
•Valproicacid is available as a tablet, capsule, and solution.
•Carbamazepine is availablein tablet, capsule, and chewable forms.
•Lamotrigine is available as a tablet in oral dissolving and chewable
forms.
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12. Adverse Effects
•Lithium:Lithium may cause tremors, weight gain, or lead to
hypothyroidism.
•Due to lithium's excretion via the kidneys, adverse effects manifest in
the form of nephrogenic diabetes insipidus and, more rarely, chronic
tubulointerstitialnephritis.
•About 20 to 40% of patients taking lithium chronically develop
polyuria and polydipsia.
•Fortunately, the nephrogenic diabetes insipidus that occurs due to
lithium therapy is managed similarly with thiazide diuretics, NSAIDs,
and a low salt diet.
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13. Adverse Effects
•ValproicAcid:Valproicacid'sadverse effects include weight gain and
GI disturbances such as nausea and vomiting, as well as alopecia,
tremor, and easy bruising, most probably owing to its effects on
coagulation. About 5to 10% of patients placed on a long-term
valproicacid regimen develop transaminitis, although a substantial
amount of cases resolve on their own without necessity for
discontinuing the regimen. Other more serious forms of valproicacid
toxicity include encephalopathy secondary to hyperammonemia,
hepatotoxicity, and acute pancreatitis.
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14. Adverse Effects
•Carbamazepine:Carbamazepine has both systemic and neurological side
effects. The systemic adverse effects are dual-faceted, including GI and
integumentary systems. GI upset is characterized by nausea, vomiting,
diarrhea, and hyponatremia. The integumentary issues characteristically
are pruritisand rash. The neurologic defects associated with
carbamazepine therapy include headache, dizziness, vision changes (blurry
or diplopia), lethargy, and drowsiness.
•Lamotrigine:Lamotrigine therapy has a similar adverse effect profile as
carbamazepine in that it involves rash and nausea as prominent side
effects. Neurologic side effects include diplopia, dizziness, and tremor.
•The adverse effects of the different mood stabilizers appear in further
detail under the 'Contraindications' and 'Toxicity' headings below.
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15. Contraindications
•Prescribers need to pay attention to the metabolism and processing of the
mood-stabilizing agents as their accumulation in the body can lead to their
toxicities and adverse effects.
•Lithium clearance is through the kidneys. As renal function decreases with
age, prescribers should exercise caution in patients over the age of 60 and
those with renal failure.
•Additionally, lithium should be avoided in those with cardiac failure due to
its ability to alter the functioning of the sodium-potassium transporter,
which can worsen arrhythmias. Lithium should be discontinued within the
first three months of pregnancy, and the decision to resume therapy is up
to the patient’s psychiatrist and whether the benefits of treatment
outweigh the risks. There is some evidence that lithium can cause facial
malformations in infants born to mothers on lithium therapy.
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16. Contraindications
•Valproicacid should be avoided in pregnancy and harbors a serious
adverse effect of fatal hepatotoxicity. It may also cause pancreatitis,
hyponatremia, headache, nausea, vomiting, weight gain, diarrhea,
and abdominal pain.
•Lamotrigine and carbamazepine are both capable of causing Stevens-
Johnson syndrome; therefore, patients should learn to monitor
themselves for any skin changes or new rashes after initiation of a
mood stabilizer regimen with either of these drugs
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17. Monitoring
•Before initiating lithium therapy, the clinician should perform a
thorough physical exam that includes palpation of the thyroid gland
and obtain creatinine, blood urea nitrogen, and thyroid function test,
including T3, T4, and TSH levels, along with a urinalysis and
electrocardiogram.
•Due to valproicacid’s ability to cause fatal hepatotoxicity, LFTs are
necessary before initiating therapy to establish a baseline for the
comparison of LFTs for follow-up monitoring.
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18. Toxicity
•Treatment with the ion lithium affects multiple organ systems, most notably the
central nervous system and the GI system, causing tremors, twitching,
drowsiness, a feeling of sluggishness, vomiting, diarrhea, and loss of appetite.
Most minor symptoms of toxicity are treatable by adjustment of the medication
dose.
•Lithium's toxicity profile is also remarkable for a decreased ability to concentrate
urine, hypothyroidism, weight gain, and hyperparathyroidism. The use of lithium
during pregnancy is not without risks, so assessing the benefits vs. risks is a
requirement before discontinuing lithium during pregnancy. Hyperparathyroidism
is a consistent finding associated with lithium use, so calcium levels should be
checked before and monitored throughout the duration of pharmacotherapy. It
bears mention that elderly patients are more vulnerable to lithium toxicity.
Incases of lithium toxicity, dialysis can be performed and is the treatment of
choice, owing to lithium'slow molecular weight. Lithium clearance should be
maximized in hypovolemic patients by normalizing sodium and water in patients
with low-volume status.
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19. Toxicity
•Valproicacid toxicity is manifested most commonly as central nervous
system depression and potential cerebral edema, potentially leading
to coma and respiratory depression. These manifestations can occur
alongside pancreatitis and hyperammonemia. The healthcare team
needs to recognize toxicity as management requires a focus on
maintaining the airway and supportive care.
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20. Enhancing Healthcare Team Outcomes
•Mood stabilizers represent a class of medications that can be expertly used in
treatment regimens for bipolar mania and bipolar depression when used and
managed correctly. The evaluation of specific mood-stabilizing agents must be
tailored to each patient’s diagnosis and needs; this is where a team-based
approach to pharmacologic management of bipolar disorder is well-deserved.
The fact that the common medications included in this class have significant drug-
drug interactions merits close scrutiny. Therefore, the patient’s clinician should
always confer with a pharmacist to decide which agent would perform best, given
the patient’s current needs.
•Aside from the initial council necessary before initiating a mood stabilizer
regimen, the patient will need to follow up regularly for monitoring. Nursing can
play a significant role in both of these activities. This will ensure that the agent is
both functional and efficacious for the patient and not causing any untoward side
effects or toxicities. In this way, clinicians and their teams of vital nursing and aid
staff can keep a close watch on patients to ensure that the drugs they are taking
are still working in their favor.
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21. Enhancing Healthcare Team Outcomes
•Overall, everyone on the interprofessionalhealthcare team: clinicians,
nurses, and pharmacists, can benefit frombroadening their knowledge on
the distinguishing characteristics of the different major mood stabilizers.
Regarding the receiving and admitting process of patients, medical staff
should be clinically knowledgeable about the various agents that their
patients might be on, for it could be a reason or, at the very least, a related
etiology as to their hospital or outpatient clinic visit in the first place. A
more widespread knowledge about these agents would be beneficial to
have or learn from any hospital standpoint.
•In short, interprofessionalmanagement of mood-stabilizing medications
will lead to better patient outcomes with fewer adverse events.
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22. 1. Classification:
•Lithium:It's a classic mood stabilizer and is particularly effective in
the treatment of bipolar disorder.
•Anticonvulsants (e.g., valproicacid, carbamazepine):These
medications are also used as mood stabilizers, especially in cases
where lithium is not well-tolerated.
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23. 2. Dose and Administration:
•Lithium:
•Start with a low dose and gradually increase to a therapeutic level.
•Regular monitoring of blood levels is crucial due to a narrow therapeutic
range.
•Anticonvulsants:
•Doses may vary based on the specific medication.
•Administered orally in divided doses to maintain a steady level in the
bloodstream.
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24. 3. Effects:
•Stabilizing Mood:The primary goal is to prevent and manage mood
swings, reducing the frequency and intensity of manic and depressive
episodes.
•Prevention of Mania and Depression:Mood stabilizers aim to
prevent both manic and depressive states, promoting a more stable
emotional state.
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25. 4. Side Effects:
•Lithium:
•Potential for kidney and thyroid issues.
•Tremors, weight gain, and gastrointestinal disturbances.
•Anticonvulsants:
•Drowsiness, dizziness, and potential liver function issues.
•Weight gain or loss, hair loss.
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26. 5. Routine Investigations in Monitoring:
•Blood Levels (Lithium):
•Regular monitoring is crucial to ensure therapeutic levels without toxicity.
•Blood levels should be checked regularly, especially when initiating or
adjusting the dose.
•Liver and Kidney Function Tests:
•Anticonvulsants may affect liver function; regular tests are essential.
•Lithium can impact kidney function; monitoring is crucial.
•Thyroid Function Tests (Lithium):
•Regular checks for thyroid function due to potential thyroid side effects.
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27. 6. Patient Education:
•Compliance with Medication:
•Stress the importance of taking medications consistently.
•Recognizing Side Effects:
•Educate patients on potential side effects and the importance of reporting
them promptly.
•Importance of Monitoring:
•Emphasize the need for regular blood tests and check-ups.
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28. 7. Individualized Treatment:
•Patient-specific Factors:
•Consider individual patient factors, such as age, comorbidities, and
concurrent medications, in choosing and adjusting treatments.
•Regular Reassessment:
•Periodically reassess the need for continued treatment and adjust
medications accordingly.
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29. 8. Collaborative Care:
•Multidisciplinary Approach:
•Collaborate with other healthcare professionals, including psychiatrists,
psychologists, and primary care physicians, for comprehensive patient care.
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